Pathophysiologie und Androgendeprivationstherapie des kastrationsresistenten Prostatakarzinoms

Advanced prostate cancer that progresses under androgen deprivation therapy has long been thought to be refractory to further hormonal treatment. The identification of the mechanism of cancer cells has revolutionized this understanding. Today it is known that castration-resistant prostate cancer (CRPC) still receives signals through the androgen receptor transduction pathways and furthermore is sensitive to hormone therapy. New substances, such as abiraterone, enzalutamide (MDV3100) and TAK 700 target these mechanisms of resistance of cancer cells, stop testosterone production and show not only better tolerance but also effective antitumor activity. Due to the heterogeneity of tumors with cells in varying states of differentiation, the treatment of CRPC with androgen deprivation therapy remains a cornerstone of disease management. To what extent the experimental findings and the recommendations in the guidelines are put into practice was the subject of a survey among urologists analyzing their treatment strategies with CRPC patients.     

Prostatastanzbiopsie unter Diclofenac

BACKGROUND: The aim of this study was to evaluate the efficacy of diclofenac to reduce pain during prostate biopsy. METHODS: After prospective randomization all patients received an intrarectal lidocaine gel instillation. Group 1 (n=80) functioned as control group, group 2 (n=72) received a placebo, and group 3 (n=76) a 50 mg diclofenac suppository in addition. Patients were asked to identify their pain score (VAS 10) after the biopsy. Two weeks later, the patients were called and asked about the post-biopsy course. RESULTS: Patients in the diclofenac group had significantly lower pain scores than control or placebo group patients. Another biopsy without additional anesthesia was refused by 25% of the control group and 34% of the placebo group, but only by 11% of the diclofenac group (p<0.05). CONCLUSIONS: The preinterventional administration of diclofenac suppositories is a simple but efficient procedure for pain reduction in patients who undergo prostate biopsy.     

Versorgungssicherung unter DRG-Bedingungen

The aims of introducing the DRG system are fairer remuneration based on services provided, enhanced transparency in terms of performance, better value for money, and a better quality of care. The DRG system will lead to competition for patients, who are able to find out more thanks to the greater transparency, and thus in turn to better care. Another positive effect will be the more marked specialization of hospitals. The laws on per-case lump sum payments and on alteration of the per-case lump sum payments and also the regulation governing hospital stay thresholds will ensure adequate financial provision for the services needed. Early experience with the changeover to the DRG-System has been recorded in clinics that opted to join in 2003 before it becomes compulsory. As might have been expected, the review of the coding system is a central problem area, and this will remain a large area of activity in the future. The introduction of the DRG-System in this year when hospitals have been able to join it on a voluntary basis has been marred by the 2003 catalogue of DRGs, which is definitely one of its weak points. Its further evolution will depend heavily on involvement of the hospitals and professional medical organizations. An improved DRG catalogue and expansion of the opening clauses should provide a good basis for the changeover to DRG throughout the country in 2004.     

Zerebrale Vaskulitis unter Gemcitabin

Neoadjuvant chemotherapy consisting of cisplatin and gemcitabine was given to a 50-year-old woman suffering from transitional cell carcinoma of the bladder. Whereas the first cycle was administered without major side effects, the patient experienced a generalized tonic–clonic seizure and a prolonged cognitive deficit with the second cycle. Magnetic resonance imaging of the brain was consistent with cerebral vasculitis. The short interval between the application of gemcitabine and the neurological deterioration suggests a causal relationship. Although recent reports have linked this drug with leukoencephalopathy and vasculitis in various localizations, this is the first case of cerebral vasculitis associated with gemcitabine.     

Intrakardiale Chirurgie unter Hypothermie

Ohne Zusammenfassung     

Harnleiterersatz unter Verwendung von Darmsegmenten

When ureter damage is extensive or affects the midureter continuity can be restored using bowel segments. The principle issues of these techniques comprise reconstruction of the urinary tract preserving renal function in a long-term setting. The safety of ureters reconstructed from bowel segments has been validated in several large series as a reliable last resort solution with favorable results and low complication rates. Ureter reconstruction with bowel segments is doomed to fail in patients with short-bowel syndrome or Crohn's disease. Furthermore, the applicability in children and patients with progressive renal deficiency is severely limited. To prevent renal deterioration the use of retubularized bowel segments as a substitute for ureter defects has been postulated. Whereas antirefluxive implantation seems unnecessary in patients with a native bladder in situ or orthotopic bladder substitution, it is recommended in continent bowel reservoirs with cutaneous stoma.     

Nekrosen der Kieferknochen unter Bisphosphonattherapie

Bisphosphonates are widely used in the treatment of cancer patients with hypercalcemia and bone metastases or in osteoporosis therapy. Current reports have focused on therapy-resistant osteonecrosis of the jaws as a possible side effect of bisphosphonates. Official German drug committees have recently warned about the possibility of these side effects. So far we have experience with 12 patients showing therapy-resistant osteonecrosis of the mandible under bisphosphonate medication, three of whom received oral bisphosphonates for osteoporosis treatment. Presentation of these three cases provides more information on this clinically important side effect of oral bisphosphonate medication, also in osteoporosis therapy.     

Verlegen von Schwerverletzten unter DRG-Bedingungen

The aim of trauma networks is the transfer of severely injured patients to the next suitable hospital according to different trauma center levels. Under the terms of DRG-based payment, we must pay attention to conditions of reimbursement.     

Brusterhaltende Krebschirurgie unter plastisch-rekonstruktiven Gesichtspunkten

Zusammenfassung Die brusterhaltende Therapie des Mammakarzinoms stellt bei kleineren Tumoren eine Alternative zu radikaleren Behandlungsmethoden dar. Die erzielten kosmetischen Ergebnisse sind nicht immer zufriedenstellend. Die Korrektur dieser Deformit?ten an der nachbestrahlten Brust ist schwierig und risikoreich. Deswegen solite in die Prim?roperation bereits die Rekonstruktion der Brustdrüse mitaufgenommen werden. Für dieses operative Vorgehen werden technische M?glichkeiten aufgezeigt. Vom onkologischen Standpunkt aus erscheint dies vertretbar.      

Onkologische Beckenchirurgie unter urologischen Gesichtspunkten

The aim of the treatment of invasive bladder cancer with radical cystectomy and subsequent urinary diversion is to combine a safe oncological procedure with a satisfactory quality of life. Radical cystectomy is the treatment of choice for all patients with recurrent or multifocal high grade T1 bladder cancer, T1 tumors with high risk of progression, failure of Bacillus Calmette-Guérin treatment and muscle-invasive bladder cancer. Radical cystectomy offers excellent recurrence-free and cancer-specific survival rates as well as local tumor control in patients with organ-confined and node-negative diseases. Tumor control in non-organ-confined tumors is still satisfactory with long term recurrence-free survival (RFS) rates of about 50%. Nerve-sparing cystectomy is of importance for lower urinary tract function, including continence rates after orthotopic urinary diversion and for sexual function in males and females. Orthotopic urinary reconstruction using a neobladder achieves good continence rates. Overall quality of life after radical cystectomy remains good in most patients irrespective of the type of urinary diversion.     

CT-gesteuerte Sakroplastie unter Verwendung insufflierbarer Ballons

OBJECTIVE: The procedure of sacroplasty was introduced recently and involves the percutaneous application of cement to the sacral bone. Currently there are no standardized data available reflecting clinical results such as leakage rates or other complications. The aim of this study was to evaluate the feasibility and results of a balloon-assisted, CT-guided cement application in a controlled experimental approach. MATERIAL AND METHODS: The trials were conducted on preserved human cadaveric specimens (n=6). The cement application was supported by kyphoplasty balloons (Kyphon) on the right hand side, and was performed without balloons on the opposite side. CT scans were obtained for preoperative planning and postoperative assessment, while CT fluoroscopy was used for intraoperative guidance (Philips Brilliance 64). RESULTS: The procedure revealed a good feasibility with an average procedure time of 36.9+/-2.4 min (range 33.1-38.9). The chosen scan protocol produced the following effective doses: 0.99 mSv in females and 0.63 mSv in males per scan and 0.33 mSv (females) and 0.25 mSv (males) per CT fluoroscopy image. Extraosseous cement spreading was not observed after both balloon-assisted and conventional application. CONCLUSION: The CT-guided technique presented in this study enables surgeons to perform sacroplasty with high precision and moderate radiation exposure. Further clinical studies are necessary to show if the balloon-assisted cement application can promote lower leakage rates than the conventional technique in patients with sacral fractures.     

Splanchnikusperfusion unter Dopexamin bei kardiochirurgischen Eingriffen

The present study investigates the effects of dopexamine on the splanchnic perfusion and the general circulation in patients undergoing coronary artery bypass grafting. METHODS: 34 Patients undergoing elective coronary artery bypass grafting were randomized to receive either dopexamine (1 microg/kg/min) or placebo (0,9% NaCl. ) Cardiac output was measured by thermodilution using a pulmonary artery catheter. Splanchnic blood flow was determined by constant infusion technique of indocyanine green dye (ICG) using a hepatic vein catheter. RESULTS: Under steady state conditions before surgery, dopexamine increased systemic oxygen supply and cardiac output by an increase in heart rate and stroke volume, with no increase in systemic oxygen demand. Before surgery dopexamine increased splanchnic blood flow together with an increase in cardiac output. After cardiopulmonary bypass dopexamine increased splanchnic perfusion without a concomittant rise in cardiac output. CONCLUSION: These results provide evidence that dopexamine improves splanchnic blood flow in patients with coronary artery disease before and after pulmonary bypass without impairment of general hemodynamics.     

Resorbierbare Calciumphosphatkeramik im Tierexperiment unter Belastung

Zusammenfassung Segmentscheiben aus keramischen Werkstoffen auf der Basis von Tricalcium- bzw. Tetracalciumphosphat mit einem durchgehend offenen System von Röhrenporen von 45 Vol- % wurden anstelle einer herausgesÄgten 7 mm dicken Knochenscheibe in die Tibia von Hunden implantiert. Nach Abnahme der Fixierung nach 12 Wochen belasteten die Hunde in physiologischer Weise die operierten Gliedmaßen. Histologisch wurde festgestellt, daß die Osteotomiespalten mit der Keramik primär verheilt waren. Die Tricalciumphosphatkeramik war nach 10 Monaten weitgehend resorbiert und durch Knochengewebe ersetzt. Die Tetracalciumphosphatkeramik war dagegen vollständig erhalten und in den Poren von lamellärem Knochengewebe durchwachsen, das sich dicht und bindegewebsfrei auf der Keramik auflagerte. Zwischen Knochen und Keramik bestand ein mechanisch nicht lösbarer Verbund.Die untersuchten Keramiken waren gewebeverträglich und sind u. E. geeignet, die heute verwendeten Knochentransplantate z.T. zu ersetzen. Tricalciumphosphatkeramik ist an Stellen einsetzbar, an denen keine extremen Belastungen auftreten; Tetracalciumphosphatkeramik ist mechanisch stabiler und könnte auch für höher belastete permanente Implantate verwendet werden.

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Resorbable calcium phosphate ceramics under load

Summary Cylindrical implants with 45 % by volume continuous open tubular pores were prepared from ceramic materials based on tricalcium and tetracalcium phosphate and used to replace 7 mm thick bone segments in the tibiae of dogs. The treated limbs of the experimental animals were fixed for 12 weeks, after which time the dogs were allowed to move freely so that the limbs were physiologically loaded. The histological examination showed that primary bone healing had taken place between the bone and the ceramic material. After 10 months the tricalcium-phosphate-based ceramic material was resorbed and replaced by bone tissue to a large extent. The ceramic material on the basis of tetracalcium phosphate, on the other hand, had remained completely unchanged, and its pores were filled with lamellar bone tissue which was in direct contact with the implant without connective tissue. The bond between natural bone and implant was mechanically stable.The ceramic materials investigated were found to be tissue-compatible, and in our opinion they can be substituted for part of the bone transplants used today. Considering its varying strength properties, the tricalcium phosphate ceramic material can be used only in cases where no high stress is expected; the tetracalciumphosphate-based ceramic material, however, has a higher mechanical strength and can therefore be used also for larger permanent implants which have to bear high mechanical stress.

Die Untersuchungen sind Teil einer Forschungsarbeit, die das Battelle-Institut, Frankfurt am Main, im Aufrage des Bundesministeriums für Forschung und Technologie durchführte